Get Refractive Surgery Referral - Pcli: For Doctors Of Optometry

Filling out the Refractive Surgery Referral form online can enhance the efficiency of submitting patient information for refractive procedures. This guide will provide helpful and detailed instructions to ensure you complete the form accurately.

Follow the steps to fill out the Refractive Surgery Referral form online.

1. Click the ‘Get Form’ button to access the form and open it in the designated editor.
2. Begin by entering the referring doctor's information, ensuring to complete the name, address, and contact number fields.
3. Provide the patient's information, including their name, address, phone number, date of birth, and date of the exam.
4. Select the desired surgery type from the options: LASIK, PRK, Implantable Contact Lens (ICL), or Undetermined.
5. If applicable, indicate the intraocular lens (IOL) preference for Refractive Lens Exchange (RLE), selecting from single-focus, toric, or multifocal.
6. Document the recommended refractive error outcome for each eye by entering details for the right eye (OD) and left eye (OS).
7. Specify whether a contact lens trial was completed, indicating yes or no for monovision correction.
8. Outline the reasons for the patient's interest in undergoing surgery, including occupational and hobby-related details.
9. Record the patient’s ocular history, medical history, current medications (both ocular and systemic), and any known allergies.
10. Fill in details regarding corneal stability, including the type of contact lenses worn and the number of weeks contacts were removed prior to the refraction.
11. Indicate the dominant eye and document pupil size, visual acuity without correction, and the present prescription.
12. Complete the keratometry and cycloplegic refraction readings, including the intraocular pressure (IOP) for both eyes.
13. Assess the ocular motility and other examinations for both eyes, checking if they are normal for the various parts of the eye.
14. Record any abnormal findings in the anterior and posterior segments.
15. Confirm the assessment and plan, ensuring to indicate that the evaluation has been completed and the patient is deemed suitable for surgery.
16. Sign the form as the referring doctor.
17. Once all fields are completed, save the changes, and choose to download, print, or share the form as needed.

Complete the Refractive Surgery Referral form online to streamline your patient referrals.